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Page 10 of 13 Fisher et al. Plast Aesthet Res 2024;11:36 https://dx.doi.org/10.20517/2347-9264.2024.53

Once the LAP flap has been harvested, the next step in the sequence will depend on the vascular graft site
being used and the patient’s positioning. If possible, the AV grafts are harvested immediately after the flap
and anastomosed to the LAP pedicle on the back table of the operating room by one surgeon while another
surgeon closes the LAP donor site over drains. If grafts are inaccessible at this stage, the donor site should be
closed and the surgeon should then proceed with repositioning and graft harvesting.

“Back table” microsurgery
Regardless of when AV grafts are harvested in the operative sequence, they are anastomosed to the pedicle
on the back table of the operating room [Figure 8]. We find this approach to be the most technically
straightforward approach. The arterial anastomosis is frequently coupled with a 1.0 or 1.5 mm coupler,
provided that the media of the vessels is thin enough to enable the vessel to be everted over the coupler
prongs without fracturing the intima [Figure 5B]. The arterial anastomosis is hand-sewn with 10-0 suture if
the vessel walls cannot be everted appropriately. The venous anastomosis is coupled in standard fashion
(2-2.5 mm coupler size). While the back-table anastomosis work is being completed, the LAP donor site is
closed in layers over drains that are draped over the thoracolumbar fascia. It is important to close the
[28]
thoracolumbar fascia to avoid lumbar hernia, a rare but recognized complication of this surgery . We
prefer to leave 1-2 cm of the fascia open just above the pelvic bone to reduce the risk that postoperative
bleeding could produce nerve compression from hematoma near the spine. To facilitate drain care, the
drain site is positioned anteriorly near the ASIS. Negative pressure dressings are used over the donor site
closure to facilitate healing and provide added soft tissue stability against shearing forces that will
necessarily occur at the donor site as the patient lays and sits on this area. If TD AV grafts were used, the
donor site may be closed over a drain while the patient is still prone.

Flap anastomosis and inset
The patient is then repositioned to supine to anastomose the open end of the AV grafts to the recipient site
vessels. Ipsilateral donor site flaps must be rotated 180 degrees to position the pedicle medially and use the
gluteal fat to shape the superior pole of the reconstructed breast. Once the anastomosis has been completed,
the flap is inset with the skin paddle in the lower third of the reconstructed breast and closed over a drain.

Anastomoses of the proximal ends of a TD AV graft or a DIE AV graft to internal mammary recipient
vessels resemble the experience of anastomosing a free TDAP or DIEP flap to the internal mammary vessels.
Nevertheless, because inadvertent tension on the fragile anastomoses between the grafts and the LAP
pedicle must be avoided at all costs, and because there is a significantly higher revision rate for vascular
anastomosis in lumbar artery perforator flap reconstruction, we almost always remove a single costal
cartilage and prepare a longer length of recipient vessels than we would for DIEP flap or free TDAP flap.

POSTOPERATIVE CONSIDERATION
Second-stage procedures to optimize the donor and recipient sites are almost always required and are done
3 months after the reconstruction. The flaps are often reshaped to sculpt the tissue and reduce the skin
paddle, nipples are reconstructed, balancing and symmetrizing procedures are done for the contralateral
LAP donor site and contralateral breast, and scars are revised. On a case-by-case basis, in unilateral LAP
reconstructions, we make a joint decision with the patient as to how to manage the contralateral lumbar
region for symmetry (liposuction or resection), or preserve this donor site for possible future reconstructive
options.

CLINICAL OUTCOMES AND COMPLICATIONS
The ideal outcome of LAP flap reconstruction is simultaneous breast reconstruction and aesthetic body